Push back on toxic behaviors from other doctors

That’s an excerpt from an OR in St. Louis on March 12th. This is just one of the outbursts that was reported from a single, multi-hour surgery — an attending’s toxic mandate to her resident, who was poised in a precarious situation under the drapes. The rest of the OR staff caught plenty of its own abusive flak throughout the case as she denied the circulating nurse relief: “No one’s f*cking leaving! Nobody is signing out!” And to the scrub tech who didn’t have available an item that she requested: “That’s bullshit!!” she exclaimed as she stormed out of the room … providing the team with what must have been a welcome, if brief, reprieve.

There’s more in the complaint that was submitted to the hospital medical staff office (and copied to The Joint Commission, the ACGME, and the state medical board), but you get the gist. Does the military even permit this type of hazing and harassment of its basic training recruits and subordinates anymore? Medicine apparently does, despite the high talk, the “sentinel event” designations, residency program requirements and official statements on the topic issued by a host of organizations.

To the OR team members’ credit, they submitted complaints against the physician, despite their concerns for identification and retaliation. What will happen as a result is yet to be seen. Given that this physician has been reprimanded in the past for dysfunctional behavior and continues to practice without restriction today after these most recent tirades, does not necessarily exude optimism that TJC’s “zero tolerance” policy for such behavior will prevail. With almost 20 years of focus on dysfunctional physician behavior (the AMA began to study this in 1999), and statements from such organizations and associations as TJC, the ACGME, and the Federation of State Medical Boards, eradication of toxic physician behavior has not been highly effective. One wonders if the persistence of such dysfunction shows the enforcement mechanisms to be toothless and ineffectual.

I’m reminded of the Seinfeld car reservation episode wherein the desk clerk tells Jerry that no car is available for him despite his reservation.

Jerry: I don’t understand. Do you have my reservation?

Clerk: We have your reservation, we just ran out of cars.

Jerry: But the reservation keeps the car here. That’s why you have the reservation.

Clerk: I think I know why we have reservations.

Jerry: I don’t think you do. You see, you know how to take the reservation, you just don’t know how to hold the reservation. And that’s really the most important part of the reservation: the holding. Anybody can just take them.

Likewise, anybody can just make up rules, regulations, and policies. These organizations know how to make the policies, they just don’t know how to enforce the policies. And that’s really the most important part of the policy: the enforcement.

But to be fair, over the decades the culture of medicine has been slowly improving. The older physicians are dying off, and fewer of the newer ones are adopting those archaic, destructive personality traits and behaviors. Certainly, the type of behavior taking place in St. Louis isn’t a norm of daily interaction in most of our health care settings. The metaphoric ship of medical culture is slow to turn, as a colleague recently told me, but does seem to be making an almost imperceptible corrective arc toward a better destination. Might we not turn the ship a bit more quickly if we all dug in with an oar from time to time, reporting bad behaviors, making dysfunctions more transparent, shaming those that are resistant to let go of the hostile and toxic work and learning environments that they perpetuate? We all have an ability to push back on these behaviors that negatively impact workplace morale, staff turnover, our own misery index and patient care and safety.

For the moment, St. Louis holds the uncontested and dubious distinction of Dysfunctional Physician Capital of America. Surely there are other contenders out there that could use some exposure. Pick up an oar, and make a difference.